Provider Demographics
NPI:1962400754
Name:GRADY, THOMAS AUSTIN JR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:AUSTIN
Last Name:GRADY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:315-349-5921
Practice Address - Street 1:140 WEST SIXTH STREET, STE 270
Practice Address - Street 2:PHYSICIAN CARE PC
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-349-5752
Practice Address - Fax:315-349-5769
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211331207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01875598Medicaid
DD1962Medicare PIN
BB5364Medicare PIN
CC4095Medicare PIN
NYG76760Medicare UPIN
NY01875598Medicaid
060069758Medicare PIN
060060449Medicare PIN